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If I had Chronic Kidney Disease: What would I want my Doctor to Know….. Liam Plant Department of Renal Medicine, Cork University Hospital Department of Medicine, University College Cork School of Medicine
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Conceptual Framework Pathophysiological Processes Mechanisms Clinical Practice Strategies
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What happens when kidneys fail? Conceptually best viewed as loss of nephrons Conceptually best viewed as not having any dysfunction of the myriad functions of the renal epithelial cells
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Where?
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(One of the) Central Mechanism(s) HypertensionProteinuria InflammationFibrosis Angiotensin II
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Prevalent ESKD patients (n) 3505 patients 42% HD 5%Home 53% TX 786 p.m.p.
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6 Year Increase in Dialysis Prevalence 31/12/03 – 31/12/09 647 patients 64% All 78%HD 2%PD Mean (95%C.I.) 108 (65,151)All 107 (72,142)HD 1 (-17,19)PD
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Identify the Gold Standard Sensible Default
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Who gets CKD? Risk Groups 10% of adults (3-4% CKD 3+) 60% male Older adults Racial Groups Diabetes/Vascular Disease/Other How detected Screening – which groups Opportunistic Intercurrent Illness Primary presentation
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NeoErica project: 112,215 patients (12 practices) [Creat] in last 10 years - 27.4% – 74% in last 2 years Proteinuria recorded in 9.1% 24.9% had eCrClr <60ml/min (C&G) At least 5.1% of UK population CKD 3-5 (NHANES-III 4.7% of US populationCKD 3-5) Any CKD in adults – up to 10%
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Issues What would I fear………………………………….. How would I be evaluated………………………… How would I alter my lifestyle…………………….. What treatments would I wish……………………… How would I wish to be monitored and by whom………
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What would I fear………..? Premature death from non-renal complications Career, financial, family plans Badly organised care pathways Pain ‘Uraemia’ Renal Replacement Therapy
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Theoretical Construct Complications DeathESKDGFRCKDRISKHI-RISK
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How would I be evaluated..? Define presence of CKD Stratify stage of CKD; estimate rate of progression Identify underlying cause (specific measures) Target objectives
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Chronic Kidney Disease One or more of: Proteinuria Haematuria (not urological) Radiological abnormality Histological abnormality
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5 Key data points 1.Stage of CKD GFR Hypertension Proteinuria 2.Complications 3.Rate of Progression 4.Comorbidities 5.Cause of CKD
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K/DOQI Stratification StageGFR (ml/min/1.73m2) Comment 1*>90 Hypertension Structural problem 2*60-89 Hypertension Structural problem 330-59 Complications Progression/Referral 415-29 More Complications Referral/Preparation 50-14 RRT/Conservative
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Proteinuria Dipstick for Screening 24hr collection if nothing better (worse!) to do Protein/Creatinine or Albumin/Creatinine ratios Express as mg/mmol (x0.0088 for 24h) (divide by 100!) <3.0Normal 3.0 – 34.0Microalbuminuria >34.0Proteinuria
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How would I alter my lifestyle..? Stop smoking Continue drinking Sensible, healthy diet; passage to ‘elite’ diet only in special circumstances A BMI target to remember……………..
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What treatments would I wish..? Conservative treatment Specific treatment Dialysis therapies Transplantation Palliative care
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What treatment is appropriate for these patients? Review medications. Stop NSAID’s. Adjust other medications if needed because of level of CKD. · Treat BP to a target of <130/80. This may require multiple medications. ACEi/ARB are 1 st choice therapies. · If PCR >300mg/mmol – treat to target of <125/75. · If 10year CV risk estimate is >20% - consider anti-platelet agent/statin. · Encourage smoking cessation, exercise, weight loss. · Immunise against influenza and pneumococcus.
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Stage 4-5 drugs Erythropoeisis-stimulating agents Drugs for secondary hyperparathyroidism Anti-rejection drugs
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How monitored and by whom..? Conservative treatment Specific treatment Dialysis therapies Transplantation
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April 2006Corrigan Club
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‘New Good Practice’ Renal function expressed as eGFR 4-point MDRD Formula CKD classified as Stage 1-5 K/DOQI Classification Protein to Creatinine; Albumin to Creatinine ratio Detection, monitoring, referral criteria www.renal.org/CKDguide/ckd.html www.renal.org/CKDguide/ckd.html Non-visit-based Specialist advice service
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Martinez-Ramirez HR, et al. Am J Kidney Dis 2006; 47: 78-87
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Conclusion Levey AS, et al. Chronic kidney disease as a global public health problem: Approaches and positions – a position statement from Kidney Diseases Improving Global Outcomes. Kidney Int 2007; 72: 247-59. Taal M, Tomson S. UK Renal Association Clinical Practice Guidelines, 4 th Edition 2007. www.renal.org/guidelines/module1.html Irish Nephrology Society. Irish CKD Guidelines. www.nephrology.ie
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